Ideas and Innovations
Reconstructive Chimeric Superficial Circumflex Iliac Perforator Flap Including External Oblique Fascia: A Refinement of Conventional Harvesting Manuel Fernandez Garrido, MD* Shan Shan Qiu, MD, PhD† Carmen Vega Garcia, MD* Gemma Pons Playa, MD* Jaume Masiá Ayala, MD, PhD*
Summary: The superficial circumflex iliac perforator (SCIP) flap is one of the most suitable flaps to cover distal extremity defects due to its lack of bulkiness and donor site concealment. However, it is less popular than other perforator flaps due to its anatomical variations, short pedicle length, and small caliber vessels. We describe a novel design for the SCIP flap, consisting of a chimeric flap with a piece of the external oblique muscle fascia. The purpose of this design is to cover and protect the vascular anastomosis in distal lower limb defects where recipient vessels are superficial and skin coverage is poor. In addition, lengthening the pedicle with this design makes the flap more versatile. The addition of a cuff of fascia in harvesting of the SCIP flap lengthens the pedicle, allowing easier insetting of the skin paddle and providing complete protection and coverage of the vessels. This procedure allows greater versatility in inset of the skin paddle and is particularly suitable in cases where recipient vessels are superficial or when skin coverage is poor. (Plast Reconstr Surg Glob Open 2016;4:e766; doi: 10.1097/GOX.0000000000000757; Published online 28 June 2016.)
T
raditional groin flaps were first described by McGregor and Jackson1 in 1972 and Daniel and Taylor2 in 1973.3–6 In 2004, Koshima et al7 presented the superficial circumflex iliac perforator (SCIP) flap, consisting of the dissection of a large groin flap based on a single perforator rising from the superficial circumflex iliac artery (SCIA). The SCIP flap is one of the most useful flaps to cover distal extremity defects as it provides a large amount *Department of Plastic and Reconstructive Surgery, Hospital de la Sant Creu i Sant Pau, Barcelona, Spain; and †Department of Plastic and Reconstructive Surgery, Maastricht University Medical Center, Maastricht, The Netherlands. Received for publication October 12, 2015; accepted April 18, 2016. Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. DOI: 10.1097/GOX.0000000000000757
of skin and soft tissue in sites where bulkiness must be avoided. It also allows direct closure and concealment of the donor site. However, it is seldom used due to its drawbacks such as anatomical variations, short pedicle length, and small caliber vessels that frequently require a hardener and make vascular dissection difficult. Several anatomical variations of the SCIP technique have been proposed to meet clinical needs. These include the super-thin SCIP flap, sensate SCIP flap using intercostal nerves, supercharged SCIP flap using intercostal artery perforator flaps, use of vascularized iliac bone combined with the SCIP flap, vascularized groin lymph nodes combined with the SCIP flap, and SCIP–deep inferior epigastric perforator combination.7–9 Each of these modifications improves results of SCIP in specific conditions. We describe a novel variation of the SCIP flap, consisting of a chimeric flap with a portion of external oblique muscle fascia based on a small branch arising from the main pedicle of the flap. Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.
www.PRSGlobalOpen.com
1
PRS Global Open • 2016 PATIENT AND METHODS Surgical Technique
The procedure follows previous descriptions of raising this flap.7,10,11 Briefly, a line is drawn between the anterior superior iliac spine and the pubis. With the angio–computed tomographic scan and/or hand-held Doppler ultrasound, cutaneous branches of the SCIA are located in the skin paddle. First, a skin incision is made over the site where the main pedicle (superficial branch of SCIA) lies in the medial and lower part of the skin paddle. The dissection then proceeds from distal to proximal and lateral to medial, allowing incorporation of sizeable perforators in the flap. The dissection should be located in the suprafascial plane. Once the fascia of the oblique muscle is reached, care must be taken to preserve the branches running in this direction. A cuff of fascia of 4 cm × 2 cm centered on one of the sizeable branches is then taken as the pedicle is raised (Fig. 1). Once the main pedicle and a branch running toward the external oblique fascia are located and isolated with the flap, the lower incision is performed. Under direct vision, the pedicle is dissected to its origin in the femoral vessels. Figure 2 shows a schematic drawing of the location of the branches and their relationship with the main pedicle. The pedicle averages 3 mm in diameter and has 1 artery and 2 veins (the artery is about 2 mm in diameter). The whole flap is elevated and transferred to the defect. After completing the anastomosis, the cuff of fascia is placed directly on the vessels to protect the anastomosis and the pedicle. If primary closure is not possible without tension, a split skin graft can be placed over the fascia flap for coverage. The donor site can be closed directly (Figs. 1 and 2). We present the case of a 52-year-old woman who underwent a chimeric SCIP flap with external
oblique fascia following a full-thickness defect on the left dorsal foot with exposure of the tendons. Because the peritenon was gone, a free flap or pedicle flap was necessary to provide adequate coverage. We designed an SCIP chimeric flap that includes a cuff of external oblique fascia, and this piece of vascularized fascia was used to properly cover the anastomosis and vessels (Fig. 3). The vascular anastomosis was performed to the dorsalis pedis vessels in an end-toend fashion. The piece of fascia was placer over the anastomosis to protect it. The final aspect of the flap five months after surgery is shown in Figure 4. The patient could walk normally with a complete recovery of the foot movement.
DISCUSSION
The SCIP flap has undergone many variations in its design since it was first described in 2004 by Daniel and Taylor.2 These authors included both the superficial and deep branches of SCIA, which was the first free groin flap for reconstruction of the lower limb.2 More recently, with the introduction of perforator flaps, many authors have demonstrated the viability of raising large groin flaps based on a single perforator. Sinna et al12 considered the perforator should preferably arise from the deep branch of the SCIA, although other authors recommended that the inclusion of 1 dominant perforator, whether it arises from the superficial branch or the deep branch, is sufficient to nourish the flap.7,13 Further refinements of this flap have been reported, such as the super-thin flap that was raised above the Scarpa fascia so as to preserve not only the deep fat tissue but also the lymphatics, lymph nodes, and cutaneous nerves.14 Koshima et al7 described several variations of the SCIP flap, such as a supercharged SCIP flap that has an intercostal artery perforator flap, combined
Fig. 1. A, During dissection, after performing the upper incision, a branch toward the external oblique muscle fascia is isolated and a cuff of the fascia is drawn with a marking pen. The green underground is placed below the superficial branch of the SCIA. B, The whole flap is raised and the pedicle is dissected until reaching the femoral vessels. The piece of the fascia showing the corresponding branch arising from the main pedicle.
2
Garrido et al. • Superficial Circumflex Iliac Perforator Flap
Fig. 2. Drawing of the branches arising from the femoral vessels. A, Perforators of the SCIP flap arise from the superficial branch. B, Deep branch of the superficial circumflex iliac flap is spared. C, Branches toward the external oblique muscle fascia should be spared during harvesting of the flap. D, Femoral vessels.
Fig. 4. Postoperative picture of the left foot 5 months after surgery. The piece of split skin graft placed over the fascia, in the area of the anastomosis, of 1 × 2 cm (in the ankle, the most proximal scar) was hypertrophied.
oblique muscle. This addition allows more versatility in skin paddle placement and lengthens the pedicle. This variation of the SCIP flap may be particularly valuable in traumatic cases where suitable recipient vessels are located far from the wound. Moreover, in areas where the recipient vessels are superficially located and skin coverage is poor, such as the lower leg and foot, this flap may provide optimal coverage of the anastomosis.
CONCLUSIONS
Fig. 3. After a degloving injury of the foot, it was covered using a chimeric SCIP flap. A piece of fascia lying above the vessels can be seen to protect them.
with the vascularized iliac bone and the addition of groin lymph nodes or conjoined with the deep inferior epigastric perforator flap.8,9,15,16 In this report, the chimeric SCIP flap ensures coverage of the pedicle in the recipient site by including a cuff of fascia based on a branch toward the external
We described a chimeric flap that includes a cuff of external oblique fascia in harvesting of the SCIP flap. This procedure allows more versatility in insetting of the skin paddle and is particularly suitable in cases where the recipient vessels are superficial or when skin coverage is poor. Shan Shan Qiu, MD Department of Plastic and Reconstructive Surgery Maastricht University Medical Center P. Debyelaan 25 6229 HX Maastricht, The Netherlands E-mail: [email protected]
3
PRS Global Open • 2016 REFERENCES
1. McGregor IA, Jackson IT. The groin flap. Br J Plast Surg. 1972;25:3–16. 2. Daniel RK, Taylor GI. Distant transfer of an island flap by microvascular anastomoses. A clinical technique. Plast Reconstr Surg. 1973;52:111–117. 3. O’Brien BM, MacLeod AM, Hayhurst JW, et al. Successful transfer of a large island flap from the groin to the foot by microvascular anastomoses. Plast Reconstr Surg. 1973;52:271–278. 4. Harii K, Omori K, Torii S, et al. Free groin skin flaps. Br J Plast Surg. 1975;28:225–237. 5. Acland RD. The free iliac flap: a lateral modification of the free groin flap. Plast Reconstr Surg. 1979;64:30–36. 6. Chuang DC, Colony LH, Chen HC, et al. Groin flap design and versatility. Plast Reconstr Surg. 1989;84:100–107. 7. Koshima I, Nanba Y, Tsutsui T, et al. Superficial circumflex iliac artery perforator flap for reconstruction of limb defects. Plast Reconstr Surg. 2004;113:233–240. 8. Iida T, Mihara M, Narushima M, et al. A sensate superficial circumflex iliac perforator flap based on lateral cutaneous branches of the intercostal nerves. J Plast Reconstr Aesthet Surg. 2012;65:538–540. 9. Iida T, Narushima M, Yoshimatsu H, et al. A free vascularised iliac bone flap based on superficial circumflex iliac perforators for head and neck reconstruction. J Plast Reconstr Aesthet Surg. 2013;66:1596–1599.
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10. Hsu WM, Chao WN, Yang C, et al. Evolution of the free groin flap: the superficial circumflex iliac artery perforator flap. Plast Reconstr Surg. 2007;119:1491–1498. 11. Iida T. Superficial circumflex iliac perforator (SCIP) flap: variations of the SCIP flap and their clinical applications. J Reconstr Microsurg. 2014;30:505–508. 12. Sinna R, Hajji H, Qassemyar Q, et al. Anatomical background of the perforator flap based on the deep branch of the superficial circumflex iliac artery (SCIP Flap): a cadaveric study. Eplasty. 2010;10:e11. 13. Koshima I, Nanba Y, Nagai A, et al. Penile reconstruction with bilateral superficial circumflex iliac artery perforator (SCIP) flaps. J Reconstr Microsurg. 2006;22:137–142. 14. Goh TL, Park SW, Cho JY, et al. The search for the ideal thin skin flap: superficial circumflex iliac artery perforator flap–a review of 210 cases. Plast Reconstr Surg. 2015;135:592–601. 15. Iida T, Yoshimatsu H, Hara H, et al. Reconstruction of large facial defects using a sensate superficial circumflex iliac perforator flap based on the lateral cutaneous branches of the intercostal nerves. Ann Plast Surg. 2014;72:328–331. 16. Iida T, Mihara M, Yoshimatsu H, et al. Versatility of the superficial circumflex iliac artery perforator flap in head and neck reconstruction. Ann Plast Surg. 2014;72: 332–336.
Reconstructive Chimeric Superficial Circumflex Iliac Perforator Flap Including External Oblique Fascia: A Refinement of Conventional Harvesting Manuel Fernandez Garrido, MD* Shan Shan Qiu, MD, PhD† Carmen Vega Garcia, MD* Gemma Pons Playa, MD* Jaume Masiá Ayala, MD, PhD*
Summary: The superficial circumflex iliac perforator (SCIP) flap is one of the most suitable flaps to cover distal extremity defects due to its lack of bulkiness and donor site concealment. However, it is less popular than other perforator flaps due to its anatomical variations, short pedicle length, and small caliber vessels. We describe a novel design for the SCIP flap, consisting of a chimeric flap with a piece of the external oblique muscle fascia. The purpose of this design is to cover and protect the vascular anastomosis in distal lower limb defects where recipient vessels are superficial and skin coverage is poor. In addition, lengthening the pedicle with this design makes the flap more versatile. The addition of a cuff of fascia in harvesting of the SCIP flap lengthens the pedicle, allowing easier insetting of the skin paddle and providing complete protection and coverage of the vessels. This procedure allows greater versatility in inset of the skin paddle and is particularly suitable in cases where recipient vessels are superficial or when skin coverage is poor. (Plast Reconstr Surg Glob Open 2016;4:e766; doi: 10.1097/GOX.0000000000000757; Published online 28 June 2016.)
T
raditional groin flaps were first described by McGregor and Jackson1 in 1972 and Daniel and Taylor2 in 1973.3–6 In 2004, Koshima et al7 presented the superficial circumflex iliac perforator (SCIP) flap, consisting of the dissection of a large groin flap based on a single perforator rising from the superficial circumflex iliac artery (SCIA). The SCIP flap is one of the most useful flaps to cover distal extremity defects as it provides a large amount *Department of Plastic and Reconstructive Surgery, Hospital de la Sant Creu i Sant Pau, Barcelona, Spain; and †Department of Plastic and Reconstructive Surgery, Maastricht University Medical Center, Maastricht, The Netherlands. Received for publication October 12, 2015; accepted April 18, 2016. Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. DOI: 10.1097/GOX.0000000000000757
of skin and soft tissue in sites where bulkiness must be avoided. It also allows direct closure and concealment of the donor site. However, it is seldom used due to its drawbacks such as anatomical variations, short pedicle length, and small caliber vessels that frequently require a hardener and make vascular dissection difficult. Several anatomical variations of the SCIP technique have been proposed to meet clinical needs. These include the super-thin SCIP flap, sensate SCIP flap using intercostal nerves, supercharged SCIP flap using intercostal artery perforator flaps, use of vascularized iliac bone combined with the SCIP flap, vascularized groin lymph nodes combined with the SCIP flap, and SCIP–deep inferior epigastric perforator combination.7–9 Each of these modifications improves results of SCIP in specific conditions. We describe a novel variation of the SCIP flap, consisting of a chimeric flap with a portion of external oblique muscle fascia based on a small branch arising from the main pedicle of the flap. Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.
www.PRSGlobalOpen.com
1
PRS Global Open • 2016 PATIENT AND METHODS Surgical Technique
The procedure follows previous descriptions of raising this flap.7,10,11 Briefly, a line is drawn between the anterior superior iliac spine and the pubis. With the angio–computed tomographic scan and/or hand-held Doppler ultrasound, cutaneous branches of the SCIA are located in the skin paddle. First, a skin incision is made over the site where the main pedicle (superficial branch of SCIA) lies in the medial and lower part of the skin paddle. The dissection then proceeds from distal to proximal and lateral to medial, allowing incorporation of sizeable perforators in the flap. The dissection should be located in the suprafascial plane. Once the fascia of the oblique muscle is reached, care must be taken to preserve the branches running in this direction. A cuff of fascia of 4 cm × 2 cm centered on one of the sizeable branches is then taken as the pedicle is raised (Fig. 1). Once the main pedicle and a branch running toward the external oblique fascia are located and isolated with the flap, the lower incision is performed. Under direct vision, the pedicle is dissected to its origin in the femoral vessels. Figure 2 shows a schematic drawing of the location of the branches and their relationship with the main pedicle. The pedicle averages 3 mm in diameter and has 1 artery and 2 veins (the artery is about 2 mm in diameter). The whole flap is elevated and transferred to the defect. After completing the anastomosis, the cuff of fascia is placed directly on the vessels to protect the anastomosis and the pedicle. If primary closure is not possible without tension, a split skin graft can be placed over the fascia flap for coverage. The donor site can be closed directly (Figs. 1 and 2). We present the case of a 52-year-old woman who underwent a chimeric SCIP flap with external
oblique fascia following a full-thickness defect on the left dorsal foot with exposure of the tendons. Because the peritenon was gone, a free flap or pedicle flap was necessary to provide adequate coverage. We designed an SCIP chimeric flap that includes a cuff of external oblique fascia, and this piece of vascularized fascia was used to properly cover the anastomosis and vessels (Fig. 3). The vascular anastomosis was performed to the dorsalis pedis vessels in an end-toend fashion. The piece of fascia was placer over the anastomosis to protect it. The final aspect of the flap five months after surgery is shown in Figure 4. The patient could walk normally with a complete recovery of the foot movement.
DISCUSSION
The SCIP flap has undergone many variations in its design since it was first described in 2004 by Daniel and Taylor.2 These authors included both the superficial and deep branches of SCIA, which was the first free groin flap for reconstruction of the lower limb.2 More recently, with the introduction of perforator flaps, many authors have demonstrated the viability of raising large groin flaps based on a single perforator. Sinna et al12 considered the perforator should preferably arise from the deep branch of the SCIA, although other authors recommended that the inclusion of 1 dominant perforator, whether it arises from the superficial branch or the deep branch, is sufficient to nourish the flap.7,13 Further refinements of this flap have been reported, such as the super-thin flap that was raised above the Scarpa fascia so as to preserve not only the deep fat tissue but also the lymphatics, lymph nodes, and cutaneous nerves.14 Koshima et al7 described several variations of the SCIP flap, such as a supercharged SCIP flap that has an intercostal artery perforator flap, combined
Fig. 1. A, During dissection, after performing the upper incision, a branch toward the external oblique muscle fascia is isolated and a cuff of the fascia is drawn with a marking pen. The green underground is placed below the superficial branch of the SCIA. B, The whole flap is raised and the pedicle is dissected until reaching the femoral vessels. The piece of the fascia showing the corresponding branch arising from the main pedicle.
2
Garrido et al. • Superficial Circumflex Iliac Perforator Flap
Fig. 2. Drawing of the branches arising from the femoral vessels. A, Perforators of the SCIP flap arise from the superficial branch. B, Deep branch of the superficial circumflex iliac flap is spared. C, Branches toward the external oblique muscle fascia should be spared during harvesting of the flap. D, Femoral vessels.
Fig. 4. Postoperative picture of the left foot 5 months after surgery. The piece of split skin graft placed over the fascia, in the area of the anastomosis, of 1 × 2 cm (in the ankle, the most proximal scar) was hypertrophied.
oblique muscle. This addition allows more versatility in skin paddle placement and lengthens the pedicle. This variation of the SCIP flap may be particularly valuable in traumatic cases where suitable recipient vessels are located far from the wound. Moreover, in areas where the recipient vessels are superficially located and skin coverage is poor, such as the lower leg and foot, this flap may provide optimal coverage of the anastomosis.
CONCLUSIONS
Fig. 3. After a degloving injury of the foot, it was covered using a chimeric SCIP flap. A piece of fascia lying above the vessels can be seen to protect them.
with the vascularized iliac bone and the addition of groin lymph nodes or conjoined with the deep inferior epigastric perforator flap.8,9,15,16 In this report, the chimeric SCIP flap ensures coverage of the pedicle in the recipient site by including a cuff of fascia based on a branch toward the external
We described a chimeric flap that includes a cuff of external oblique fascia in harvesting of the SCIP flap. This procedure allows more versatility in insetting of the skin paddle and is particularly suitable in cases where the recipient vessels are superficial or when skin coverage is poor. Shan Shan Qiu, MD Department of Plastic and Reconstructive Surgery Maastricht University Medical Center P. Debyelaan 25 6229 HX Maastricht, The Netherlands E-mail: [email protected]
3
PRS Global Open • 2016 REFERENCES
1. McGregor IA, Jackson IT. The groin flap. Br J Plast Surg. 1972;25:3–16. 2. Daniel RK, Taylor GI. Distant transfer of an island flap by microvascular anastomoses. A clinical technique. Plast Reconstr Surg. 1973;52:111–117. 3. O’Brien BM, MacLeod AM, Hayhurst JW, et al. Successful transfer of a large island flap from the groin to the foot by microvascular anastomoses. Plast Reconstr Surg. 1973;52:271–278. 4. Harii K, Omori K, Torii S, et al. Free groin skin flaps. Br J Plast Surg. 1975;28:225–237. 5. Acland RD. The free iliac flap: a lateral modification of the free groin flap. Plast Reconstr Surg. 1979;64:30–36. 6. Chuang DC, Colony LH, Chen HC, et al. Groin flap design and versatility. Plast Reconstr Surg. 1989;84:100–107. 7. Koshima I, Nanba Y, Tsutsui T, et al. Superficial circumflex iliac artery perforator flap for reconstruction of limb defects. Plast Reconstr Surg. 2004;113:233–240. 8. Iida T, Mihara M, Narushima M, et al. A sensate superficial circumflex iliac perforator flap based on lateral cutaneous branches of the intercostal nerves. J Plast Reconstr Aesthet Surg. 2012;65:538–540. 9. Iida T, Narushima M, Yoshimatsu H, et al. A free vascularised iliac bone flap based on superficial circumflex iliac perforators for head and neck reconstruction. J Plast Reconstr Aesthet Surg. 2013;66:1596–1599.
4
10. Hsu WM, Chao WN, Yang C, et al. Evolution of the free groin flap: the superficial circumflex iliac artery perforator flap. Plast Reconstr Surg. 2007;119:1491–1498. 11. Iida T. Superficial circumflex iliac perforator (SCIP) flap: variations of the SCIP flap and their clinical applications. J Reconstr Microsurg. 2014;30:505–508. 12. Sinna R, Hajji H, Qassemyar Q, et al. Anatomical background of the perforator flap based on the deep branch of the superficial circumflex iliac artery (SCIP Flap): a cadaveric study. Eplasty. 2010;10:e11. 13. Koshima I, Nanba Y, Nagai A, et al. Penile reconstruction with bilateral superficial circumflex iliac artery perforator (SCIP) flaps. J Reconstr Microsurg. 2006;22:137–142. 14. Goh TL, Park SW, Cho JY, et al. The search for the ideal thin skin flap: superficial circumflex iliac artery perforator flap–a review of 210 cases. Plast Reconstr Surg. 2015;135:592–601. 15. Iida T, Yoshimatsu H, Hara H, et al. Reconstruction of large facial defects using a sensate superficial circumflex iliac perforator flap based on the lateral cutaneous branches of the intercostal nerves. Ann Plast Surg. 2014;72:328–331. 16. Iida T, Mihara M, Yoshimatsu H, et al. Versatility of the superficial circumflex iliac artery perforator flap in head and neck reconstruction. Ann Plast Surg. 2014;72: 332–336.
